Question

A 25-year-old man presents due to heartburn. It only occurs 1 or 2 times a month, but it is extremely noticeable when these episodes do occur. He states that eating large meals, eating late at night right before going to sleep, and excessive alcohol consumption seem to exacerbate and even initiate episodes. He has noticed that limiting the aforementioned behaviors has decreased the severity of the symptoms in recent months, but it is still occurring despite this modification. He denies any difficulty swallowing, weight loss, night sweats, chest pain, use of tobacco, or coughing up blood. Physical examination is unremarkable for any abnormalities.

Since this patient's symptoms would be classified as mild, intermittent symptoms and modifications have been attempted and failed, what would be the next best option for this patient?

1 Antacids
2 H2-receptor antagonists
3 Proton-pump inhibitor
4 Antibiotics
5 Prokinetic agents

Answer 1

Given the patient's mild, intermittent heartburn and unsuccessful lifestyle modifications, an initial trial of H2-receptor antagonists or antacids would be appropriate. These can alleviate symptoms until the patient can further evaluate with their healthcare provider if symptoms persist or worsen.

Step-by-step explanation:

The patient with mild, intermittent heartburn symptoms has already tried lifestyle modifications such as eating smaller meals and avoiding triggers like large meals, late-night eating, and excessive alcohol consumption. These lifestyle changes are often recommended before starting medications. However, the patient still experiences bothersome episodes despite these modifications. The next step in management, after lifestyle modifications have been attempted and have not been fully successful, would typically involve the use of over-the-counter medications to further alleviate symptoms.

Given the options provided and the fact that the heartburn is mild and not frequent, H2-receptor antagonists or antacids could be considered appropriate initial choices. H2-receptor antagonists, such as ranitidine or famotidine, can provide longer relief compared to antacids but may take longer to start working. Antacids can provide rapid relief, but their effect is short-lived, and they may be more suitable for very occasional symptoms. Proton-pump inhibitors like omeprazole are a more potent option and are generally reserved for more frequent or severe symptoms that do not respond to H2-receptor antagonists. Prokinetic agents and antibiotics are not indicated in this scenario without evidence of a condition such as gastroparesis or H. pylori infection, respectively.

Thus, for this patient, the next best option to manage the mild, intermittent heartburn, especially since it hasn't been successfully managed by lifestyle changes alone, would be to trial an H2-receptor antagonist. Should the patient's symptoms continue to occur or worsen, further evaluation by a healthcare provider would be warranted, potentially including a trial of proton-pump inhibitors or further diagnostic workup to rule out more serious conditions.